Cognitive Behavior Therapy for Posttraumatic Stress Disorder


Only a minority of individuals exposed to trauma will develop PTSD.  In attempting to determine the individual risk factors for PTSD, researchers have begun to observe natural recovery from trauma. One potential difference between those who recover naturally and those who continue to experience distressing symptoms might have to do with avoidance: cognitive, emotional and behavioral.

The cognitive model suggests that the belief that the world is excessively dangerous coupled with beliefs about personal incompetence is important in the development of PTSD (Foa & Rothbaum, 1998). Following a traumatic event, such beliefs might be reinforced and therefore lead to avoidance of everyday, previously normal tasks such as grocery shopping, socializing, and traveling by car. Additionally, beliefs about the importance of maintaining strict control over distressing emotions and thoughts might also be factors mediating the development of PTSD (Ehlers & Clark, 2000).  Following a traumatic event, these beliefs might lead to attempts to avoid thoughts and memories of the traumatic event and the associated upsetting emotions.

In contrast, natural recovery from trauma might be enhanced by a willingness to return, over time, to normal activities. This behavior may strengthen beliefs about personal ability to manage difficulty, that other people are not generally dangerous, and that even extremely uncomfortable emotions are manageable.

One CBT approach for PTSD systematically and strategically recreates this recovery process by targeting the tendency to avoid feared situations and distressing recollections and emotions.  By systematically approaching the avoided stimuli, the individual can learn the same lessons as the person who recovers without intervention.  With the assistance of a skilled cognitive behavior therapist, individuals can acquire more accurate and helpful beliefs about themselves, others, and the world following the experience of a traumatic event.


Ehlers, A., & Clark, D.M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38, 319-345.

Foa, E.B., & Rothbaum, B.O. (1998). Treating the trauma of rape: Cognitive-behavioral therapy for PTSD. New York: Guilford Press.

10 Cognitive Distortions

Both David Burns (bestselling author of “Feeling Good: The New Mood Therapy“ and Abraham Low (founder of Recovery, Inc.) teach techniques to analyze negative thoughts (or identify distorted thinking — what psychologists call “cognitive distortions”) so to be able to disarm and defeat them. This is one of the major precepts of cognitive behavioral therapy.

Since Low’s language is a bit out-dated, I list below Burns’ “Ten Forms of Twisted Thinking,” (adapted from his “Feeling Good” book, a classic read) categories of dangerous ruminations, that when identified and brought into your consciousness, lose their power over you. They have been helpful in my recovery from depression and anxiety. After I identify them, I consult his 15 Ways to Untwist Your Thinking.

Treating Clinical Depression

Depression can be hard to treat. It’s estimated that one in every 10 American adults battle with it.

Now there’s new evidence that different forms of therapy may work as well as antidepressants. Researchers reviewed 198 studies involving over 15,000 patients.

A total of seven different types of therapy were compared, including:

  1. interpersonal psychotherapy
  2. behavioral activation
  3. cognitive behavioral therapy
  4. problem solving therapy
  5. psychodynamic therapy
  6. social skills training
  7. and supportive counseling.

The data showed that all seven therapies were better at reducing symptoms of depression than usual care. Plus there were no significant differences between the various types of therapy.

Strategy-Driven CBT for Posttraumatic Stress Disorder

As I sit across from a new client in his early thirties, who survived an assault while at college, he begins to tell me about his previous treatments.  He describes a string of therapies addressing many of the problems that followed the traumatic event, such as chronic drug use, sleep problems, depression, rage, suicidal ideation, and risky behaviors. He tells me, “The therapists were so nice, supportive and knowledgeable.  I went week after week.  I felt better at each session, but I never got better. I just figured, “there must be something wrong with me that I can’t get better.”

Clients with PTSD often present with multiple complaints and problems, as comorbidity with other psychiatric disorders is highly prevalent (79%-88.3%; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995).  The therapist needs a well-formulated, efficient strategy for change to help the individual recover from PTSD and associated difficulties. The strategy should be based on a research-informed understanding of PTSD and a tailored conceptualization of the individual’s problems.  Guided by conceptualization and strategy, the therapist is better able to respond to the individual’s unique challenges, which can include extensive avoidance, shame, guilt, anger, substance use, suicidality, interpersonal disturbances, and more.  The ability to communicate this strategy to the individual can provide hope for the future and a framework for understanding an experience that feels frightening and chaotic.

Considering that survivors present with multiple, trauma-associated problems and many evidence-based therapies are available, the therapist can become overwhelmed with decisions such as where to begin therapy, which interventions to select, and how to respond when obstacles arise.  These decisions are even more difficult when coupled with the unsubstantiated opinions existing in the mental health field about the treatment of trauma and PTSD.  The use of an individualized, theoretically grounded, cognitive-behavioral conceptualization and strategy provides a guide for the therapist when planning treatment and helps the therapist maintain focus on an efficient course of treatment.

The conceptualization-driven course of therapy incorporates any of the possible presenting problems, with the goal of recovery from PTSD and a return to a meaningful life.

Aaron Brinen, PsyD
Beck Institute Adjunct Faculty

The Cognitive Model of Anxiety

According to the cognitive model of anxiety, individuals with a vulnerability to anxiety make biased and exaggerated appraisals of possible harm and underestimate potential resources. Their inaccurate appraisals trigger fearful thinking (anxious automatic thoughts and images) which leads to anxiety symptoms. To cope with the experience of anxiety, patients employ unhelpful strategies that provide temporary relief, but also perpetuate anxiety and lead to further problems in the long-term.

The chart below lists the core cognitive content and unhelpful coping strategies associated with a number of common anxiety disorders. 

Core Cognitive Contents of Anxiety




Generalized anxiety
disorder (GAD)
Excessive apprehension about danger in a wide array of situations; intolerance of uncertainty Hypervigilance; chronic worry; avoidance of distressing mental imagery
Panic disorder Catastrophic misinterpretation of bodily/mental experiences requiring immediate intervention Hypervigilance for symptoms; overt or subtle avoidance; help-seeking

Health anxiety

Excessive fear of having a catastrophic medical problem Hypervigilance for physical symptoms

Specific phobia

Anticipated harm or disgust reaction in specific situations or upon exposure to specific object Avoidance

Social anxiety disorder

Fear of negative evaluation or humiliation in social or evaluative situations Avoidance: hyperattention to internal processes
 Obsessive compulsive disorder  Repetitive, excessive worries about potential dangers and responsibility for preventing harm Thought suppressing and/or compulsive behaviors to reduce distress
Posttraumatic stress disorder and acute stress disorder Fear of re-experiencing horror of a trauma Avoidance